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Habitual dislocation of the shoulder: causes, symptoms, diagnosis, treatment
Last reviewed: 05.07.2025
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ICD-10 code
S43.0. Dislocation of shoulder joint.
[ What causes recurrent shoulder dislocation?
Sometimes repeated dislocations occur without much force - it is enough to abduct and rotate the shoulder outward. For example, swinging the arm to hit a ball, trying to throw a stone, putting hands behind the head, putting on clothes, combing hair, etc. Periodically, shoulder dislocations can happen in sleep. Such dislocations are called habitual.
The development of habitual shoulder dislocation can be facilitated by damage to the vascular-nerve bundle, glenoid labrum, and fractures of the glenoid cavity of the scapula. But most often, habitual dislocation develops as a complication of traumatic anterior dislocation due to artificial errors: neglect of anesthesia or its inadequacy, rough methods of reduction, insufficient immobilization or its absence, early physical activity. As a result, damaged tissues (capsule, ligaments, and muscles surrounding the joint) heal by secondary tension with the formation of persistent scars, muscle imbalance appears. Instability of the shoulder joint develops, resulting in habitual dislocation.
Symptoms of habitual shoulder dislocation
Dislocations are repeated, and as their frequency increases, the load required for their occurrence decreases, and the method of their elimination becomes simpler. As a result, the patient refuses medical care and eliminates dislocations independently or with the help of others. After reduction, pain in the shoulder joint usually bothers, which goes away within a few hours, sometimes 1-2 days. We observed patients who had 500 or more dislocations, which occurred 1-3 times a day. Patients self-reduce the shoulder in various ways: by traction of the healthy arm on the dislocated shoulder, abduction and rotation of the dislocated arm, traction on the dislocated arm, the hand of which is clamped between the knees of the patient, etc.
Classification of habitual shoulder dislocation
According to G.P. Kotelnikov, instability of the shoulder joint should be divided into compensated and decompensated forms, with the first one having three stages: subclinical, mild clinical and pronounced clinical manifestations. Such gradation allows for a more subtle assessment of the patient's condition and, on a pathogenetic basis, selection of the optimal method of surgical treatment and a complex of subsequent rehabilitation therapy. In particular, at the stage of subclinical manifestations, conservative treatment is used, which, according to the researcher, prevents the transition to the next stage of the pathological process.
Diagnosis of habitual shoulder dislocation
Anamnesis
History of traumatic shoulder dislocation, after which dislocations began to recur without adequate load. Retrospective study of the treatment of the primary injury, as a rule, reveals a number of gross errors.
Inspection and physical examination
External examination reveals atrophy of the muscles of the deltoid and scapular regions; the configuration of the shoulder joint is not changed, but its functions are significantly impaired. There is a limitation of active external rotation of the shoulder when it is abducted to 90° and the forearm is bent due to fear of dislocation (Weinstein's symptom) and passive rotation in the same position and for the same reason (Babich's symptom). A positive Stepanov's symptom is characteristic. It is checked in the same way as Weinstein's symptom, but with the difference that the patient is placed on the couch on his back. When rotating the shoulders, the patient cannot reach the surface on which he is lying with the back of the hand of the affected hand.
An attempt to passively bring the arm to the body with active resistance of the patient on the affected side is easy, on the healthy side - not (symptom of decreased strength of the deltoid muscle). Raising the arms upward and simultaneously deviating them backward reveals a limitation of these movements on the affected side (the "scissors" symptom). There are a number of other signs of habitual shoulder dislocation, described in detail in the monograph by A.F. Krasnov and R.B. Akhmedzyanov "Shoulder Dislocations" (1982).
Laboratory and instrumental studies
Using electromyography, a decrease in the electrical excitability of the deltoid muscle is detected (Novotelnov's symptom).
A radiograph of the shoulder joint reveals moderate osteoporosis of the humeral head. Sometimes, a depressed defect is noted on its posterolateral surface, located behind the apex of the greater tubercle. The defect is clearly visible on the axial radiograph. A similar, but less pronounced defect can be detected in the area of the anterolateral edge of the glenoid cavity of the scapula.
Treatment of habitual shoulder dislocation
Conservative treatment of habitual shoulder dislocation
Patients with habitual shoulder dislocation need to be operated on, since conservative methods of treating habitual shoulder dislocation are not successful.
Surgical treatment of habitual shoulder dislocation
There are more than 300 methods of surgical treatment of habitual shoulder dislocation. All interventions can be divided into five main groups, not counting the methods that have only historical significance. We present these groups with an illustration of each (1-2 methods that have become the most widespread).
Joint capsule operations are the forerunners of interventions for habitual shoulder dislocation, during which surgeons excised excess capsule with subsequent corrugation and suturing.
Bankart (1923) noted that in habitual shoulder dislocation, the anteroinferior edge of the cartilaginous labrum is torn from the bony edge of the glenoid cavity of the scapula, and proposed the following method of surgical treatment. The apex of the coracoid process is cut off using an anterior approach and the muscles attached to it are brought down, opening the shoulder joint. Then, the torn edge of the cartilaginous labrum is fixed in place with transosseous silk sutures. The joint capsule is sutured, forming a duplication, over which the ends of the previously dissected subscapularis tendon are sutured. The apex of the coracoid process of the scapula is sutured transosseously, and then sutures are applied to the skin. The surgical intervention is completed with plaster immobilization.
The Putti-Platt operation is a simpler intervention from a technical point of view. Access to the joint is similar to the previous operation, but the dissection of the subscapularis tendon and capsule is done with non-coinciding incisions, followed by separation of these formations from each other. Sutures are applied with strong internal rotation of the shoulder, creating a duplication of the capsule, and in front of it - a duplication of the subscapularis tendon.
In our country, these operations have not found wide application due to relapses: their frequency in the first case ranges from 1 to 15%, and in the second intervention - up to 13.6%.
Operations to create ligaments that fix the head of the humerus. This group of operations is the most popular and numerous, with about 110 variants. Most surgeons used the tendon of the long head of the biceps muscle to stabilize the shoulder joint. However, in methods where the tendon was cut when creating the ligament, a significant number of unsatisfactory results were noted. Researchers associated this with a disruption in the nutrition of the cut tendon, its degeneration and loss of strength.
A.F. Krasnov (1970) proposed a method for surgical treatment of habitual shoulder dislocation that is free of this drawback. The intertubercular groove is exposed by an anterior incision. The tendon of the long head of the biceps muscle is isolated and taken on a holder. Part of the greater tubercle is undercut from the inside and deflected outward in the form of a valve. A vertical groove with oval ends is formed under it, into which the tendon of the long head is transferred. The bone valve is put in place and fixed with transosseous sutures. Thus, the tendon located intraosseously subsequently intimately fuses with the surrounding bone and forms a semblance of the round ligament of the femur, becoming one of the main components that prevents the shoulder from subsequent dislocations.
After the operation, a plaster cast is applied for 4 weeks.
The operation was performed on more than 400 patients, they were observed for 25 years, only 3.3% of them had relapses. A retrospective study of the causes of relapses showed that degeneratively changed, thinned, frayed tendons were used to create the ligament, which were torn during repeated trauma.
To avoid this cause of relapse, A.F. Krasnov and A.K. Povelikhin (1990) suggested strengthening the biceps tendon. It is implanted into a preserved allotendon. The allograft is sutured to the tendon along its entire length, and the lower end is immersed in the muscle belly of the biceps, and only after this is the strengthened tendon moved under the valve.
Bone operations. These surgical interventions involve the restoration of bone defects or the creation of arthrorises - additional bone stops, protrusions that limit the mobility of the humeral head. A convincing example of such methods is the Eden operation (1917) or its variant proposed by Andin (1968).
In the first case, an autograft is taken from the tibial crest and tightly inserted into the depression created in the anterior part of the neck of the scapula so that the end of the transplanted bone rises 1-1.5 cm above the glenoid cavity.
Andina took a transplant from the iliac wing, sharpened its lower end and inserted it into the neck of the scapula. The upper smoothed end protrudes forward and serves as an obstacle to the displacement of the head of the humerus.
Another group of bone operations involves subcapital rotational osteotomy, which subsequently limits external rotation of the shoulder and reduces the possibility of dislocation.
The disadvantage of all bone surgeries is the limitation of shoulder joint function.
Muscle surgeries involve changing muscle length and correcting muscle imbalances. An example is the Mangusson-Stack procedure, which involves transferring the subscapularis muscle to the greater tuberosity to limit shoulder abduction and external rotation. Limiting the latter two movements by 30-40% reduces the risk of shoulder dislocation, but relapses still occur in 3.91% of patients.
In 1943, F.F. Andreev proposed the following operation. Part of the coracoid process with the attached muscles is cut off. This bone-muscle component is passed under the tendon of the subscapularis muscle and sewn back into place. In Boychev's modification, the outer part of the pectoralis minor muscle is also moved. Relapses in the Andreev-Boychev operation were noted in only 4.16% of patients.
Combined operations are interventions that combine methods from different groups. The most famous is the operation by V. T. Weinstein (1946).
The soft tissues and capsule of the shoulder joint are dissected by an anterior incision in the projection of the intertubercular groove. The tendon of the long head of the biceps brachii is isolated and moved outward. The shoulder is rotated as much as possible until the lesser tubercle appears in the wound. The subscapularis muscle, which is attached here, is cut longitudinally for 4-5 cm, starting from the tubercle. Then the upper bundle is crossed at the lesser tubercle, and the lower bundle at the end of the longitudinal incision. The tendon of the long head of the biceps brachii is brought under the separated stump of the subscapularis muscle remaining at the lesser tubercle and fixed with a U-shaped suture, and the stump itself is sutured to the upper end of the subscapularis muscle. After the operation, a soft bandage is applied in the adducted position of the arm for 10-12 days. The recurrence rate, according to various authors, ranges from 4.65 to 27.58%.
The same group includes the operation by Yu. M. Sverdlov (1968), developed at the N. N. Priorov Central Institute of Traumatology and Orthopedics: tenodesis of the tendon of the long head of the biceps brachii is combined with the creation of an additional autoplastic ligament that fixes the head of the humerus. An anterior incision is made from the coracoid process along the projection of the intertubercular groove. The isolated tendon of the long head of the biceps is retracted outward. A flap measuring 7x2 cm is cut out with the base upward from the tendons attached to the coracoid process of the muscles. The resulting defect is sutured. The flap is sewn with catgut in the form of a tube. The shoulder is retracted to 90° and rotated outward as much as possible. The joint capsule is opened medially from the lesser tubercle. A longitudinal groove is made in the neck of the humerus with a chisel, the newly created ligament is placed in it and stitched to the outer edge of the joint capsule, and below - to the humerus. The inner leaf of the capsule is stitched to the outer one.
The intertubercular groove is cleaned, many small holes are drilled and the tendon of the long head of the biceps muscle is placed in it, which is pulled downwards and fixed with silk transosseous sutures. Below, the overstretched tendon is sutured in the form of a duplication, and then the wound is sutured layer by layer. A plaster bandage is applied for 4 weeks.
In the presence of an impression defect of the humeral head, surgical intervention is performed using the method of R.B. Akhmedzyanov (1976) - bone autoplasty of the "house roof" type.
To summarize the section on surgical treatment of habitual shoulder dislocation, we believe that choosing the optimal method is a difficult decision. The difficulty is that the results in most cases are assessed based on the researcher's data (whose results will certainly be better) and one test for relapses. And although this is an important, it is not the only or the main indicator. For example, the combined Lange operation - a combination of the Zhden and Megnusson-Stack operations - gives only 1.06-1.09% of relapses. However, after operations on bones and muscles separately, and especially in combination (Lange's method), very often stiffness in the shoulder joint develops and, naturally, there will be no relapse of dislocation.
Also unsafe are those interventions that require (without special indications) opening the shoulder joint.
We will not refute the standard truth on duty that the choice of method should be individual in each specific case and that the method that the surgeon has mastered perfectly is good. All this is true. But how can one find the optimal method in a given case? In order to choose an acceptable method of surgical treatment for a specific patient and obtain favorable results, the following conditions are necessary.
- Accurate diagnosis of shoulder joint pathology:
- type of dislocation - anterior, inferior, posterior;
- are there any intra-articular injuries - rupture of the cartilaginous labrum, impression defect of the head of the humerus, defect of the glenoid cavity of the scapula;
- Are there any extra-articular injuries - rotator cuff tear?
- The method must be technically simple, and the surgical intervention must be gentle, with a minimal degree of trauma, physiological in relation to the ligament-capsular and muscular apparatus.
- The method should not involve creating restrictions of movement in the shoulder joint.
- Compliance with the terms and scope of immobilization.
- Adequate complex treatment during the period of immobilization and after its elimination.
- Correct labor expertise.
It seems to us that the method of operation by A.F. Krasnov (1970) has most of the listed advantages. It is technically simple, gentle and highly effective in terms of long-term results. 35 years of observation and surgical treatment of more than 400 patients showed that the functions of the shoulder joint were preserved in all cases, and relapses were only 3.3%.